Provider Demographics
NPI:1831417591
Name:BEATTY KWARTA, ELIZABETH SHEA (ELIZABETH BEATTY RD)
Entity type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:SHEA
Last Name:BEATTY KWARTA
Suffix:
Gender:F
Credentials:ELIZABETH BEATTY RD
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:SHEA
Other - Last Name:BEATTY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ELIZABETH BEATTY
Mailing Address - Street 1:622 W 16TH ST UNIT 2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-1187
Mailing Address - Country:US
Mailing Address - Phone:970-218-8248
Mailing Address - Fax:
Practice Address - Street 1:5841 S MARYLAND AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60637-1447
Practice Address - Country:US
Practice Address - Phone:773-702-1489
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-05
Last Update Date:2010-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164004271133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered